• Aditi Ranade, Prakash Ramsinghani, and Camille Noel.
• Department of Internal Medicine, St. Luke's-Roosevelt Hospital Center, Columbia University College of Physicians and Surgeons, New York, New York 10025, USA. gsandhu@chpnet.org
• J Emerg Med. 2011 Jul 1;41(1):35-8.

BackgroundAccording to the Centers for Disease Control and Prevention, the risk of fatal malaria in non-endemic countries can be reduced greatly if physicians are alert to the atypical presenting features of malaria.Case ReportA patient arrived in the United States from Nigeria 2 days before presenting to an emergency department (ED) with sore throat, dry cough, fever (without chills), headache, and severe lethargy. A presumptive diagnosis of influenza-like illness was made. The patient improved after symptomatic treatment and was therefore discharged from the ED; she continued with her travel. After 24 h, the patient presented to our ED with symptoms suggestive of meningitis. The analysis of the cerebrospinal fluid was normal. A peripheral blood smear was diagnostic of falciparum malaria (parasitic index of 1). Because the disease was acquired from a chloroquine-resistant endemic area, the patient was treated with quinine and doxycycline, and she responded well.ConclusionIn this era of heightened influenza alert, differentiating between influenza-like illness and malaria can be challenging. Patients with a history of travel to a malaria-endemic area in the preceding year should undergo a complete blood count (CBC), hepatic panel, and blood smear. Due to logistic reasons, the result of a blood smear may not be available immediately. Thrombocytopenia and hyperbilirubinemia each has a positive predictive value of 95% in the presumptive diagnosis of malaria. Patients who do not appear sick, and those who have a normal CBC and hepatic panel, may be treated symptomatically and discharged (with follow-up advised). Those with a presumptive diagnosis of malaria or unclear speciation should be admitted for anti-malarial therapy.Copyright © 2011 Elsevier Inc. All rights reserved.

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